Syneron, Ltd. (Yokneam, Israel) recently released the eMatrixradiofrequency (RF) device delivering significant skin rejuve-nation results. Experts believe that this fractional RF modality,branded Sublative Rejuvenation™, belongs in a treatmentcategory of its own. “Ultimately Sublative Rejuvenation is anRF technology very different from laser fractional rejuvena-tion,” according to Stephen Bassett, M.D., medical directorof ShapeCYMRU (Swansea, Wales, U.K.). “Scientifically, theapproach seems to be exactly the opposite of what we seewith laser technology because the effect is concentrated inthe dermis and almost skips the epidermis altogether. It iseffective for a much broader range of patients because skintype is less of an issue.”continued on page 3

September/October 2009Circulation 20,000www.miinews.com

The concept behind fractional tech-nologies is simple: a pattern of ener-gy is applied to the skin impactingfractions of the dermis, surroundedby healthy tissue which helps to speedthe healing process. Fully ablative CO2resurfacing achieved great results, butdespite its efficacy, the associated risksand lengthy downtime caused the aes-thetic community to virtually abandonthis treatment.

Since the unveiling of non-ablativefractional rejuvenation in 2004, thetechnology has taken the aesthetic com-munity by storm. Although risk anddowntime were reduced, numeroustreatments were required to obtaincomparatively modest results anddarker skin types were unsuitable fortreatment. Further developments ledto ablative fractional resurfacing, mostoften utilizing a CO2 or Er:YAG laser.These modalities offered rejuvenationresults approaching those seen withfully ablative CO2 resurfacing with-out the disadvantages.

Syneron radically shifted the con-cept of fractional resurfacing into anew direction by replacing laserenergy with bi-polar RF, according toDavid J. Goldberg, M.D., director oflaser research in the department ofdermatology at the Mount Sinai Schoolof Medicine (New York City, N.Y.).“By and large, the effect of lasermodalities is greatest at the surface,and less below the skin’s surface. Thetechnology has been termed sublative

because the bulk of the effect occursbeneath the epidermis and at sub-ablative levels of heating, with littledisruption occurring on the surface.This is best for optimal dermal stimula-tion of neocollagenesis. It’s exactly theopposite of what we expect with lasertreatments. This makes Sublative Re-juvenation a radically different ap-proach to skin rejuvenation and withmore than 25 years in this field I donot use terms like ‘radical’ lightly.”

“Of course there’s nothing wrongwith fractional laser treatment,” headded. “It’s terrific, but there is a limitto how aggressive we can be withthat technology because of the ener-gies involved, and its application isvery skin type dependant.”

Michael H. Gold, M.D., director ofthe Gold Skin Care Center (Nashville,Tenn.) agreed; “Post-inflammatory hyper-pigmentation is a risk with any of thesetechnologies. For a skilled user, that riskwas dramatically reduced by fractionalmodalities, but it still exists. However,with Sublative Rejuvenation the risk issignificantly diminished.”

Sublative Rejuvenation with eMatrixwas introduced to the industry inOctober 2008. The Matrix RF appli-cator which performs Sublative Re-juvenation is FDA cleared for derma-tological procedures requiring abla-tion and skin resurfacing. “Syneron’sgoal was to develop an ablative frac-tional treatment that was not laser or

Sublative Rejuvenation MaximizesDermal Impact to Achieve Significant ResultsBy Kevin A. Wilson, Contributing Editor

THE Aesthetic Guide September/October 2009 www.miinews.com 3

Before Tx

Eight days after one Sublative Rejuvenation Tx

Photos courtesy of Michael H. Gold, M.D.

David J. Goldberg, M.D.Director of Laser ResearchDepartment of DermatologyMount Sinai School of MedicineNew York City, NY

Michael H. Gold, M.D.DirectorGold Skin Care CenterNashville, TN

“The technology has beentermed sublative becausethe bulk of the effectoccurs beneath the epider-mis and at sub-ablativelevels of heating, with littledisruption occurring onthe surface.”

THE Aesthetic Guide September/October 2009 www.miinews.com4

light-based,” explained Amy FormanTaub, M.D., dermatologist and founderof the SKINQRI research center(Lincolnshire, Ill.). “Syneron has a lotof experience with bi-polar RF. Theywanted to figure out not only how tocause a matrix of fractional ablativeinjury with this technology, but howto vary the parameters so that themodality would exhibit the flexibilitynecessary to treat multiple indicationsin the future.”

“As results were noticed we beganto realize that it isn’t about the abla-tion,” said Dr. Taub, who is a princi-pal investigator for U.S. trials withSublative Rejuvenation. “When webegan using Sublative Rejuvenation,we were amazed at the wrinklereduction and tightening achieved,because epidermal impact was sominimal. Dermal impact was muchgreater. Of course you have to gothrough the epidermis to reach thedermis, but with traditional ablativefractional lasers you get a column oftissue damage, which is actually moreof an inverted cone shape, where thehole in the epidermis is larger thanthe width of the area affected in thedermis. Users of ablative fractionalresurfacing are often treating sundamage but they’re also looking forwrinkle reduction and tightening.”

Sublative Rejuvenation providesmuch more dermal remodeling andtightening than epidermal remodel-ing, in a completely novel way, Dr.

Taub explained. “Only 5% of the skin’ssurface is affected by either ablationor coagulation. The unique pyramidshape of this treatment is critical to theoverall effect, which is a deep volu-metric sub-surface heating.”

According to Moshe Lapidoth, M.D.,head of the laser unit at Rabin MedicalCenter in Tel Aviv, Israel, one break-through is that treatment with SublativeRejuvenation is very tolerable with anexcellent safety profile, even for darkerskin types. “Because of the shape ofthe impact the higher concentration ofepidermal melanin in darker skinnedpatients is not an issue making Sub-lative Rejuvenation a suitable treatmentfor our patient population.”

Sublative Rejuvenation holds a lotof promise for a number of reasons;foremost the possibilities for treatingdarker skin types. “This may be Sub-lative Rejuvenation’s most importantadvantage,” noted Dr. Taub. “Peoplewith darker skin types age differentlythan those with lighter skin types,they develop volume loss, loss in lax-ity and some dynamic wrinkling,without the fine surface wrinklingassociated with aging of Caucasianfaces. It’s more of a folding. SublativeRejuvenation promises real softeningof even deep lines, resulting in skintightening and textural changes thatdark skinned patients cannot expectwith lasers or light-based modalitiesdue to safety constraints. I think this

Moshe Lapidoth, M.D.Head of Laser UnitRabin Medical CenterTel Aviv, Israel

Before Tx

After three Sublative Rejuvenation treatmentsPhotos courtesy of Amy Forman Taub, M.D.

Amy Forman Taub, M.D.Dermatologist and FounderSKINQRILincolnshire, IL

THE Aesthetic Guide September/October 2009 www.miinews.com 5

technology is also going to help im-prove acne scars in darker skinnedpatients because of the constraints ofusing lasers.”

Successfully treating skin of colorhas historically been a challenge forHema Sundaram, M.D., F.A.A.D., adermatologist in Rockville, Md. “Eth-nically, my practice is very diversebecause it’s located in suburban Wash-ington, D.C.,” she said. “My waitingroom on any given day looks like theUnited Nations, so treating a varietyof skin types is a special interest ofmine.”

“With laser or light-based modali-ties we had a catch-22 situation,” Dr.Sundaram continued. “On one sideyou could increase the fluence forenhanced efficacy, but you’d causetoo much collateral damage to theepidermis. This could lead to post-inflammatory hyperpigmentation whichis quite distressing to patients. On theother side you could play it safe, byultimately under treating the patient,leading to less collateral damageand reduced efficacy. However, thepatient is left underwhelmed andunsatisfied.”

According to Dr. Sundaram, “Thetechnology has advanced gradually.Our understanding of how and whythings happen has improved. We’verefined protocols, improved coolingmechanisms and lengthened pulsewidths to maximize thermal relaxation

time, but we seem to be at a standstillas far as lasers are concerned. Sub-lative Rejuvenation sidesteps all thisbecause RF is all about control of thecurrent as it relates to impedance, notabsorption, like lasers. The deliveredenergy creates a pyramid shape inthe skin barely impacting the epider-mis, which is where the pigment isconcentrated. Sublative Rejuvenationalmost completely bypasses the tradi-tional problems we expect to dealwith for skin of color.”

Dr. Sundaram described how sheused Sublative Rejuvenation success-fully on a 47 year old woman fromAfrica with skin type V. “She wasexperiencing drooping of the malarfat pad and formation of jowls, as wetypically see in patients of this ethnictype. There was also scarring fromacne and chicken pox which wasbecoming more apparent with age.She had been to several other practi-tioners who told her there wasn’t asuitable treatment for her.”

“We wanted to treat all these indica-tions as well as improve the overall tex-ture of her skin,” Dr. Sundaram ad-vised. “Sublative Rejuvenation, cou-pled with FotoFacial RF to treat her pig-mentary issues, jump started a processthat will continue for several monthsafter treatment, with apparent ongoingcollagen remodeling. She’s very pleasedwith the significant improvement in skintexture and quality, as well as thereduced appearance of scarring. Givenher experience, Sublative Rejuvenationwas a revelation to her. It is a trulyadvanced modality that belongs in itsown category.”

“Sublative Rejuvenation is a differentmodality than we’re used to,” added Dr.

Before Tx

After four Sublative Rejuvenation treatmentsPhotos courtesy of Tess Mauricio, M.D.

Hema Sundaram, M.D., F.A.A.D.DermatologistRockville, MD

“The delivered energycreates a pyramid shapein the skin barely impact-ing the epidermis, whichis where the pigment isconcentrated. SublativeRejuvenation almost com-pletely bypasses the tra-ditional problems weexpect to deal with forskin of color.”

THE Aesthetic Guide September/October 2009 www.miinews.com6

Taub. “When discussing ablative lasers,we think in terms of light being absorbedby a chromophore, creating a thermalreaction impacting the epidermis, and tosome degree the dermis, all in an effortto get heat to where it will stimulate neo-collagenesis as a secondary effect. WithSublative Rejuvenation, we send RF ener-gy through a tiny ablation in the epider-mis and it spreads out to literallycoagulate demarcated portions of thedermal tissue. It’s more than simple heat-ing, it is more targeted and at a muchhigher temperature. There is some abla-tion of tissue, and patients see a slough-ing off or peeling of tiny scabs in the firstfew days after treatment, but it’s thecoagulation effect in the dermis that stim-ulates tightening and the subsequentneocollagenesis.”

Tiny electrodes are arranged in agrid of positive and negative electrodearray. “The electricity flows through thearray, forming a closed circuit via theskin of bi-polar RF, leaving a pattern ofablative wounds on the skin’s surfacejust before penetrating the deeper skinzones,” Dr. Taub explained. This isvery different than the monopolar RFeveryone is used to, which is a singleelectrode that effects the tissue via acapacitive coupling. With SublativeRejuvenation it’s the control of the cur-rent flow in the bi-polar current arraythrough dry skin, and into the deppertissue that creates the desired effect.Since it’s a closed circuit, the energydoesn’t wander. The impedance of theskin is what generates the thermaleffect and causes coagulation.”

The bottom line, according to Dr.Taub, is that dermal impact is muchgreater than epidermal impact. “Unlikelaser modalities it isn’t simply about thedepth and absorption of energy. The

electrode configuration and the controlof current, determined by tissue imped-ance, is what majorly controls depthand shape of wounding; therefore,wound depths and shapes are pre-dictable and static.”

The treatment protocol is simpleand tolerable. “We use a water basedanesthetic for about 30 minutes, whichwe then wash off. The skin is cleanedand dried with at least 70% alcohol,preferably 90%. The skin must be ab-solutely dry. This is essential with Sub-lative Rejuvenation because it helpsto increase and equalize the surfaceskin impedance and contributes to aprecise delivery of energy,” Dr. Taubnoted. An immediate response of edemaand erythema changes the impedanceand the energy transmission characteris-tics so you can’t go over an area againduring the same treatment session.”

Pain during treatment has been re-ported as 0, 1 or 2 on a scale of one tofour. “Some patients don’t even ask fora break during treatment, it’s that toler-able,” Dr. Taub shared. “You’ll neverneed anything more than topical anes-thetic.” Cold air is not used during treat-ment and since Sublative Rejuvenationis not laser or light-based, goggles arealso unnecessary. Treating a whole faceshould take 20 minutes or less.

“Afterward we apply an emollientcream on the patient before theyleave,” Dr. Taub continued. “They mightlook a little red or swollen for a coupleof hours, but it goes away quickly.Occasionally patients feel a heating up– a sort of burning sensation – withinhalf an hour after treatment.”

According to Dr. Taub, the primaryindication for Sublative Rejuvenation

Acne scarring before Tx

Acne scarring one month after one SublativeRejuvenation Tx

Photos courtesy of Michael H. Gold, M.D.

THE Aesthetic Guide September/October 2009 www.miinews.com8

technology will be wrinkle reductionleading to tightening, as well as over-all rejuvenation, at least in the short-term. “We can even tackle foreheadlines, crow’s feet or nasolabial folds,things you might not effectively treatwith a laser unless you’re going high-ly ablative. “Usually to get this kindof tightening, you need a very highenergy treatment and considerablelaser surface coverage, which meansa lot of downtime,” Dr, Taub stated.This is significant because the entrypoint into the dermis is very small withSublative Rejuvenation, so downtimeis very short.

“There will also be a market forthose afraid of botulinum toxin injec-tions, laser treatments or those whodon’t like the idea of maintenance,especially with injections,” Dr. Taubadded. “This is especially true formen. Many of my male patients whoseem to be turned off by injectablesor the idea of repetitive treatmentshave been open to the concept ofSublative Rejuvenation.”

Dr. Taub feels it is also important topoint out that Sublative Rejuvenationdoes not provide pigmentary correc-tion. “Sublative Rejuvenation is not alaser or light-based modality, so youcannot treat lentigines or pigmenta-tion as the surface coverage is sosmall – only 5%. However, what doeshappen – and this is a key differencebetween Sublative Rejuvenation andlaser rejuvenation – is that the skinquality changes. Every patient describesa smoothing of the skin, a texturalchange that cannot be observed inbefore and after photography. It’s dif-ficult to explain and is most likely relat-ed to dermal impact but that is whatpatients notice most.”

Dr. Taub is currently studying Sub-lative Rejuvenation combined withMatrix IR (Syneron’s fractionated diodelaser with bi-polar RF) for acne scars.“We’ve enrolled 20 subjects and ahigh percentage of them have skintypes IV and V. Less than one-quarterhave actually completed the course offive treatments with three months of fol-low-up; however, preliminary resultshave been promising,” she reported.“Most patients feel they are improvingor their spouses and/or co-workershave noticed a difference. Patients willundergo four or five treatments andthose who’ve had a higher number oftreatments are seeing better results.We’ve had no complications so far.”

Dr. Bassett has also seen excellentresults with Sublative Rejuvenation forresurfacing and treatment of acnescarring. “Patients think it’s fabulous.They find it to be very tolerable. I likethat it works even on old acne scarsthat have been previously resistant totherapy. This is a big issue in the U.K.because the quirks of our medicalsystem have stunted the growth ofacne scar treatment until recently sothere’s a huge market.”

Lori Brightman, M.D., of the Laserand Skin Surgery Center of New York(New York City, N.Y.) has startedusing Sublative Rejuvenation. With asingle treatment, Dr. Brightman hasobserved results. “I have seen somegood results with off label treatment ofstretch marks as well, which I didn’t

Before Tx

After three Sublative Rejuvenation treatmentsPhotos courtesy of Serge Dahan, M.D.

Before Tx

After one Sublative Rejuvenation TxPhotos courtesy of Stephen Bassett, M.D.

Stephen Bassett, M.D.Medical DirectorShapeCYMRUSwansea, Wales, U.K.

“Usually to get this kind oftightening, you need avery high energy treatmentand considerable laser sur-face coverage, whichmeans a lot of downtime.”

expect. Interestingly, I have also noteda reduction in telangiectasia of thescars I have treated.”

As often happens in science, a for-tuitous mistake spawned a burgeon-ing study of Sublative Rejuvenationfor port-wine stains. “I accidentallytreated only half a scar and duringrecovery we noticed the vessels in thetreated side of the scar were gone.There was a clear line of demarca-tion,” Dr. Brightman elaborated. “WhenI treated a patient with striae rubra,we saw a similar effect. Now I am fur-ther exploring this unique finding forother treatment indications.”

Another future application is perio-ral lines, although in Dr. Taub’s opin-ion, the energy isn’t quite high enoughyet. “When the next generation is cre-ated it might be useful for perioral linesbecause it not only softens lines, it tight-ens the surrounding area.”

Dr. Lapidoth presented on SublativeRejuvenation at a recent meeting ofthe American Society for LaserMedicine and Surgery. “Our histolog-ical and clinical results with SublativeRejuvenation are very encouragingand interesting. In my experience, Sub-lative Rejuvenation is comparable oreven better in some cases than non-ablative or ablative fractional laser re-juvenation. Superficial damage is min-imal, and the effect is greater as youreach deeper into the dermis. Downtimeis generally low depending on the

treatment parameters, adjusted accord-ingly to the patient’s condition and tol-erance.”

“With Sublative Rejuvenation, thedowntime is as low as is claimed, whichis somewhat rare,” Dr. Bassett added.“In terms of what patients experience,it’s almost none. There’s a differencebetween clinical downtime and socialdowntime. Clinical downtime may bedefined by a variety of criteria, butsocial downtime is simply how longpatients feel they must stay in aftertreatment, for whatever reason. Rednessmay take a day or two to subside, butpatients can apply make-up 12 hoursafter treatment if they wish. Furthermore,there isn’t a complicated post-proce-dure protocol or skincare regimen todeal with. Downtime from the patientperspective is easily less than half thatof what they’d experience with a lasertreatment.”

THE Aesthetic Guide September/October 2009 www.miinews.com9

Before Tx

After two Sublative Rejuvenation treatmentsPhotos courtesy of Stephen Bassett, M.D.

Lori Brightman, M.D.Laser and Skin Surgery Center ofNew YorkNew York City, NY

“In my experience, Sub-lative Rejuvenation is com-parable or even better insome cases than non-abla-tive or ablative fractionallaser rejuvenation.”

Acne scarring before Tx

Acne scarring one month after one SublativeRejuvenation TxPhotos courtesy of Michael H. Gold, M.D.